Canterbury Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Shepherdstown, West Virginia.
- Location
- 80 Maddex Drive, Shepherdstown, West Virginia 25443
- CMS Provider Number
- 515179
- Inspections on file
- 21
- Latest survey
- March 18, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Canterbury Center during CMS and state inspections, most recent first.
A resident reported that sink water was too hot and required staff assistance to cool it, and a surveyor confirmed the water was uncomfortably hot during inspection. Water temperature checks in several rooms, conducted with the MD, revealed readings between 118 and 128°F, with the MD acknowledging the high temperatures. The facility did not adequately control water temperatures, resulting in an environment not free from accident hazards.
The facility did not complete required competency evaluations for five nurse aides, as confirmed by a review of staff files and an interview with the Consulting Administrator, who acknowledged that no competency records existed for these staff members in the past year.
Surveyors found that kitchen staff failed to document temperatures for the walk-in refrigerator and freezer, left a large box of cookie dough open in the freezer, and did not maintain cleanliness in the resident pantry, where expired oatmeal was also found. The ice machine was missing a required water filter, as confirmed by the Maintenance Director. These issues reflect lapses in kitchen sanitation, food storage, and equipment maintenance.
Staff failed to maintain infection control standards by mishandling clean linen, storing personal items and medications with linens, leaving soiled briefs in shared bathrooms, and placing trash and linen bags on the floor. Additionally, hand hygiene was not provided to residents before meals, dirty trays were mixed with clean ones during meal service, dinner trays were left out overnight, and laundry machine filters were not cleaned daily. These actions and inactions were confirmed by interviews with various staff members.
Multiple rooms and common areas were found with unfinished drywall, bulging and stained walls, cracked tiles, overflowing trash cans, and brown substances in bathrooms and on ceilings. Staff confirmed these issues, and a resident reported ongoing concerns about dark spots on the ceiling that had not been addressed despite repeated requests. The facility did not provide adequate housekeeping and maintenance services, resulting in an environment that was not clean, safe, or homelike.
Survey results were not posted in a location easily accessible to residents, families, or legal representatives, as required. Despite signage indicating the survey results were available in the lobby, they were not found there during multiple observations. The Administrator later located the survey book in the business office, confirming it was not accessible to those who needed it.
Multiple documents containing residents' personal and medical information, including names, diagnoses, medication lists, and controlled substance records, were found unsecured in a hallway wall file outside the nursing office. The DON confirmed the documents were placed with the blank side up, but they remained accessible to anyone in a high-traffic area.
A resident's discharge status was incorrectly documented in the MDS as discharge to a hospital, when in fact the resident was taken home by family with home health and medical follow-up arranged. The MDS Coordinator confirmed the error, resulting in an inaccurate assessment record.
A resident receiving oxygen therapy was repeatedly observed with her oxygen concentrator set at 4 L/min, contrary to a physician's order for 2 L/min by nasal cannula. Multiple observations and record reviews confirmed the oxygen was not administered as prescribed until staff intervention.
The facility did not update daily nurse staffing postings to reflect the actual hours worked by RNs, LPNs/LVNs, and CNAs for multiple days. The posted information did not match the hours worked by direct care staff, as confirmed by record review and staff interview.
Multiple cognitively intact residents reported that staff do not routinely offer evening snacks, and snacks are only provided if specifically requested, with limited options available. The Dietary Manager confirmed that only pre-ordered snacks or a small selection of snack cakes are accessible, and no additional snacks are available after the kitchen closes.
Garbage and used medical supplies were found scattered around the dumpster area with the lids left open. The Maintenance Director confirmed the presence of trash and medical supplies on the ground, potentially affecting all residents in the facility.
Surveyors found that two residents had uncovered urinary catheter bags visible to others—one in bed and another moving through the hallway in a wheelchair. Both residents' catheter bags were not covered, and staff confirmed the lack of covers, with one resident stating he had never been offered one.
Two residents were not provided with morning care and assistance according to their stated preferences, with one resident repeatedly receiving care much later than requested and another lacking documentation of her morning routine preferences. Staff did not consistently honor resident choices regarding waking time and morning care, and these preferences were not always reflected in care plans or records.
A resident's grievance form was not completed or logged, and the required written decision was not issued, contrary to the facility's grievance policy. The administrator confirmed that no completed copy of the grievance form could be found.
Staff failed to investigate and report injuries of unknown origin and allegations of neglect for two residents. One resident had unexplained bruising that was not investigated or reported as required by policy, and another resident's family reported skin damage and lack of bathing, but the facility delayed investigation and did not report the allegation to state authorities in a timely manner.
The facility did not promptly report or investigate two separate allegations involving suspected abuse and neglect. In one instance, a resident was found with an unexplained bruise, and the DON did not initiate an investigation or report the injury as required. In another case, a family member reported that a resident developed pressure ulcers and was not receiving regular baths; although the facility communicated with APS, it failed to report the incident and investigation results to the appropriate state authority within the required timeframe.
A resident was found with a large, unexplained bruise on her upper arm, which was not initially recognized or investigated by the DON. Although a NP later assessed the injury, the facility did not follow its policy to investigate or report the injury of unknown origin as required.
A resident did not receive showers or baths as ordered or preferred, with documentation showing only one shower and two bed baths provided in a 30-day period. The resident expressed dissatisfaction with her hygiene, and the administrator confirmed the lack of documentation for scheduled showers.
A dependent resident with incontinence was not assessed or provided incontinence care at the required intervals. The resident's MPOA reported frequently finding the resident soiled, and documentation confirmed that after an initial morning check, no further assessments were recorded. Staff acknowledged that checks should occur every two hours but did not follow this protocol.
Surveyors identified that for two residents, monthly medication regimen reviews by a pharmacist were not completed, and physician responses to pharmacist recommendations were missing. The DON confirmed that required documentation and physician follow-up were not available.
A resident with a history of malnutrition and weight loss did not receive her requested cereal and milk for breakfast on multiple occasions, despite repeated requests from her and her family and clear documentation on her tray ticket. Staff confirmed that kitchen errors led to the omission of requested items, requiring nursing staff to intervene.
The facility did not ensure all staff had thorough background checks, as required by Virginia state regulations. A nurse aide, employed since 2006, lacked a WV CARES eligibility letter, which became mandatory in 2016. The DON confirmed the absence of this documentation, despite the aide working prior to an illness. This issue was identified during a review of staff records.
The facility did not ensure RN coverage for eight consecutive hours daily, affecting all residents. On two occasions, no RN was scheduled or worked, as confirmed by the DON, who cited staffing shortages.
The facility failed to retain original staff postings for at least 18 months, as required. The deficiency was identified when the DON could not provide the original Staff Posting Sheets for the first quarter of 2024, affecting all 58 residents.
The facility failed to properly contain waste in the dumpster area, affecting multiple residents. Observations on three occasions revealed trash, including used gloves, masks, and cigarette butts, scattered around the dumpster and extending to the city road.
The facility failed to support resident self-determination by not adhering to shower preferences for several residents. One resident reported receiving showers only once every two weeks, while another experienced conflicts between shower schedules and preferred activities. Other residents were not given choices between showers and bed baths, and some had inconsistent shower availability. The DON acknowledged ongoing issues with shower schedules and documentation, contributing to the deficiency.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in care. A resident on fluid restriction received excess fluids without a care plan, while another legally blind resident lacked a plan for daily activities. A resident with edema and another with dementia had no care plans for their conditions. Additionally, a resident with hemiplegia faced anxiety due to improper call light placement, which was not addressed in their care plan.
The facility failed to administer medications on time for several residents, including those with diabetes and gangrene, and did not complete required neuro checks after a fall. Additionally, a critical oxygen level was not reported to a physician for a resident with CHF and atelectasis. These deficiencies were confirmed by the DON and a registered nurse.
A medication cart was found unlocked and unattended, posing a potential hazard by allowing unauthorized access to medications. The DON confirmed the issue, and an LPN highlighted a faulty lock mechanism. Facility policy requires carts to be locked when unattended.
The facility failed to monitor and document side effects and behaviors for three residents receiving antianxiety and antidepressant medications. A resident with Alzheimer's and anxiety was not monitored for side effects of buspirone. Two other residents, one with depressive disorder and another receiving lorazepam for seizures, also lacked proper documentation of side effects and behaviors, as confirmed by the DON.
The facility did not provide a substantial evening snack to all residents, affecting those without a dietary order or the ability to request one. Residents reported the lack of snacks during a council meeting, and an LPN confirmed snacks were only given to those with a diagnosed need. A tour showed limited snack options.
The facility failed to maintain an effective infection control program. A resident had uncleanable gauze and tape on their wheelchair, and a physical therapist assistant did not use PPE while treating a resident under contact precautions for CDiff, using hand sanitizer instead of soap and water.
The facility failed to assist a resident with personal grooming, resulting in noticeable facial hair, and did not serve meals simultaneously to residents at the same table, causing delays. Additionally, a resident was not asked about voting in an upcoming election, despite its importance to him.
A resident with limited mobility due to a stroke expressed that his call light was often out of reach, as it was placed on his nondominant side. An LPN confirmed the call light was not accessible, acknowledging the resident's need for it to be on the right side.
A resident with a legal guardian experienced a fall, but the facility failed to notify the guardian, only attempting to contact the resident's son. The resident lacked capacity for medical decisions, and the WV DHHR was appointed as the legal guardian. Despite this, the facility did not inform the guardian of the fall, as confirmed by staff interviews and record reviews.
A resident's privacy was compromised during catheter care when a nurse aide failed to close the door and blinds. Additionally, an elopement binder with sensitive resident information was left unattended in the lobby, accessible to the public. The facility administrator acknowledged the privacy issue.
A resident's grievance about a missing wheelchair was not properly documented or resolved by the facility. Despite multiple reports to staff, the resident did not receive follow-up or resolution, and the social worker failed to track the grievance, assuming it was resolved after the wheelchair was initially found.
A facility failed to update the PASRR for a resident diagnosed with Major Depressive Disorder. The resident's PASRR, last completed in early 2014, did not reflect the diagnosis made later that year. The DON confirmed the need for a new PASRR to include the updated diagnosis.
A resident's care plan was not updated to reflect a change in dialysis pick-up time, leading to a discrepancy between the care plan and actual care. The resident's dialysis schedule was changed to a 10:00 AM pick-up, but the care plan still indicated a 05:30 AM pick-up. This oversight was confirmed by the DON during a survey.
The facility failed to maintain the hygiene of a resident, as observed during an inspection, highlighting a significant lapse in care.
A resident with pressure ulcers did not receive necessary treatments as ordered, including missed applications of skin prep and protective cream, and failure to elevate heels with pillows. Additionally, scheduled wound care for a Stage III sacral ulcer and unstageable heel injuries was not performed, and checks on a low air loss mattress were missed. These deficiencies were confirmed by the DON.
The facility failed to provide proper respiratory care for two residents. A nurse did not follow sterile techniques during tracheostomy care for one resident, compromising the sterile field. Another resident did not receive prescribed breathing treatments for several days, as confirmed by the DON. These actions were contrary to facility policy and physician orders.
A facility failed to provide adequate dialysis care and adhere to fluid restrictions for a resident. Hemodialysis Communication Records were often incomplete or missing, lacking essential post-dialysis assessments. Additionally, the resident received more fluids than prescribed, exceeding the fluid restriction order. These issues were confirmed by the DON and a registered nurse.
The facility failed to monitor side effects and behaviors for two residents prescribed antipsychotic medications. One resident with Alzheimer's and dementia was on Olanzapine, and another with similar conditions was on Seroquel. In both cases, there was no documentation of monitoring for side effects as required by physician orders, confirmed by the DON.
Failure to Maintain Safe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to ensure that the resident environment was as free from accident hazards as possible, specifically regarding excessively high water temperatures in resident rooms. During interviews and inspections, a resident reported that the water was too hot and required staff assistance to adjust the temperature, although she had not been burned. Direct inspection by the surveyor confirmed that the water temperature at the resident's sink was uncomfortably hot. Further temperature checks conducted with the Maintenance Director revealed sink water temperatures ranging from 118 to 128 degrees Fahrenheit in multiple rooms, with the Maintenance Director acknowledging the high readings and noting that the temperature would decrease if the water was left running. These findings indicate that the facility did not adequately control water temperatures in resident areas, creating a potential accident hazard.
Lack of Competency Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides had completed competency evaluations, as evidenced by the absence of such evaluations in the staff files for five nurse aides. During a review of staff records, no competency evaluations were found for these individuals. An interview with the Consulting Administrator confirmed that the facility was behind on completing competencies and that there were no records of competency evaluations for these nurse aides within the past year.
Deficiencies in Kitchen Sanitation, Food Storage, and Equipment Maintenance
Penalty
Summary
During an initial kitchen tour, surveyors observed that the walk-in refrigerator and freezer did not have documented temperature logs, and a large box of cookie dough in the freezer was left open to the air. In the resident pantry, a drawer was found to be dirty and littered with sugar, salt, and pepper, and an upper cabinet contained a box of oatmeal that was expired. The Infection Preventionist confirmed both the expired oatmeal and the unclean drawer. Additionally, the kitchen's ice machine was found to be missing the required water filter as specified by the manufacturer's guidance, a fact confirmed by the Maintenance Director. These findings indicate failures in maintaining a clean and sanitized kitchen environment, proper food storage, and equipment maintenance, as required by professional standards for food service safety.
Multiple Infection Control Failures in Linen, Food Service, and Hygiene Practices
Penalty
Summary
Facility staff failed to maintain proper infection prevention and control practices in several key areas. Clean linen was mishandled, with staff returning linen that had fallen on the floor back to the cart, and personal items such as sweaters, hand lotion, air freshener, topical medications, and hand sanitizer were found stored with clean linens on multiple occasions. Soiled briefs were observed in trash cans in shared bathrooms, and bags of trash and linen were left on the floor in multiple hallways, with linen barrels overflowing in the soiled utility area. Additionally, dirty plate covers and breakfast trays were placed on meal carts with clean lunch trays during meal service, and dinner trays were left at the nurse's station overnight. Washing machine filters in the laundry room were not cleaned daily as required. Staff also failed to follow infection control protocols when handling food trays and trash, and did not provide residents with hand hygiene before meals. For example, a CNA did not offer to wash or sanitize a resident's hands before serving breakfast. These lapses in infection control practices were confirmed by interviews with staff, including RNs, CNAs, the DON, and the laundry supervisor, who acknowledged the deficiencies and improper handling of linens, trash, and food service items.
Failure to Maintain Clean and Homelike Environment Due to Inadequate Housekeeping and Maintenance
Penalty
Summary
The facility failed to maintain a homelike, clean, and safe environment for its residents by not providing adequate housekeeping and maintenance services. Multiple resident rooms and common areas were observed to have unfinished drywall, bulging and stained walls, cracked tiles, overflowing trash cans, and brown substances present in bathrooms and on ceilings. These conditions were confirmed by staff during interviews, who acknowledged the presence of unfinished repairs, unclean bathrooms, and the need for maintenance intervention. Specific observations included a three-foot section of unfinished drywall above beds, rips in wallpaper, yellowish stains around toilets, and overflowing trash cans in shared bathrooms. Additionally, the shower room had ceiling tiles with brown substances, and several resident bathrooms had bulging walls with brown stains and cracked tiles. A resident reported ongoing issues with dark spots on the ceiling in their room, which had been repeatedly requested to be painted over several months, as documented in resident council meeting minutes. The Maintenance Director confirmed that several rooms and the shower room required repairs and replacement of ceiling tiles. The lack of timely response to maintenance requests and the presence of unsanitary and unfinished conditions throughout the facility contributed to the failure to provide a clean, comfortable, and homelike environment for residents.
Survey Results Not Readily Accessible to Residents and Families
Penalty
Summary
The facility failed to post the results of its most recent survey in a location that was readily accessible to residents, family members, and legal representatives. During two separate observations, survey results were not found on the bookshelf or anywhere else in the lobby, despite signage indicating their location. When interviewed, the Administrator was unable to locate the survey book in the designated area and later found it in the business office, confirming that it was not accessible as required.
Failure to Secure Resident Medical Records in Public Hallway
Penalty
Summary
The facility failed to secure and protect residents' personal and medical information, as multiple documents containing identifiable health information were found in an acrylic wall file holder mounted in a hallway outside the nursing office. On the date of observation, these documents included resident names, room numbers, diagnoses, code status, vital signs for twenty-nine residents, prescription information for a newly admitted resident, medication listings for thirty-one residents, and a controlled drug administration record. Additionally, shift change controlled substance inventory count sheets were present. The Director of Nursing confirmed that the documents had been placed in the file holder with the blank side facing up, but acknowledged their presence in a heavily trafficked area where they were accessible to anyone.
Inaccurate MDS Discharge Status Documentation
Penalty
Summary
The facility failed to accurately document a resident's discharge status in the Minimum Data Set (MDS) assessment. Record review showed that the MDS for a resident was coded as discharge to a short-term general hospital, while a Social Services note indicated that the resident was actually picked up by their daughter to be taken home, with arrangements made for home health services and a medical appointment at the VA Medical Center. During an interview, the MDS Coordinator confirmed that the MDS was incorrectly marked as discharge to hospital instead of discharge to home, reflecting an inaccurate assessment of the resident's status during the observation period.
Failure to Follow Physician's Order for Oxygen Therapy
Penalty
Summary
A resident who was somewhat hard of hearing and receiving oxygen therapy was observed multiple times with her oxygen concentrator set at 4 liters per minute, despite a physician's order specifying oxygen at 2 liters per minute by nasal cannula. The discrepancy was noted during several observations over two consecutive days, with the oxygen flow rate remaining at 4 liters per minute throughout this period. Record review confirmed the physician's order for 2 liters per minute, and staff interviews verified that the oxygen was not set according to the prescribed rate prior to correction.
Failure to Accurately Update Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to update its Daily Nurse Staffing Forms to accurately reflect the actual hours worked by registered nurses, licensed practical nurses or licensed vocational nurses, and certified nurse aides for five reviewed days. Record review and staff interview confirmed that the posted staffing information did not match the actual hours worked by direct care staff on those days. The Consulting Administrator acknowledged that the daily staff postings were not edited to reflect the true hours worked by nursing staff responsible for resident care.
Failure to Routinely Offer and Provide Evening Snacks to Residents
Penalty
Summary
The facility failed to provide evidence that evening snacks were routinely offered to residents, as required. During a resident council meeting, multiple cognitively intact residents reported that staff do not ask if residents want an evening snack. Residents stated that snacks are only provided if specifically requested, and the available options are limited, typically to graham crackers or snack cakes. One resident recalled only being offered an evening snack on a single occasion and expressed excitement about receiving it, while council members agreed that staff do not proactively offer snacks in the evening. An interview with the Dietary Manager confirmed that snacks ordered by a physician are prepared in advance, and the pantry is stocked daily with a rotating selection of snack cakes. For residents without physician-ordered snacks, only these limited options are available, and any special requests must be entered into the computer system at least one day prior. No other snacks are available after the kitchen closes in the evening, further limiting access for residents who may want snacks outside of scheduled meal times.
Improper Storage and Disposal of Garbage and Medical Supplies
Penalty
Summary
The facility failed to properly store garbage and refuse, as observed in the dumpster area where the lids were left open and the surrounding area was polluted with garbage and used medical supplies. This was confirmed during an interview with the Maintenance Director, who verified the presence of trash and medical supplies on the ground around the dumpster. The deficiency had the potential to affect all 61 residents residing in the facility at the time of the observation.
Failure to Cover Catheter Bags Compromises Resident Dignity
Penalty
Summary
Surveyors observed that the facility failed to maintain residents' dignity and respect by not covering urinary catheter bags for two residents. One resident was seen in bed with an uncovered, half-full catheter bag hanging off the foot of the bed in clear view of anyone passing by. A nurse confirmed that the catheter bag should have been covered. Another resident was observed moving through the hallway in a wheelchair with an uncovered catheter bag in his lap. This resident stated he had never been offered a cover for his catheter bag and expressed a desire to have one. A registered nurse acknowledged that the resident did not have a cover for his catheter bag. These observations demonstrate that the facility did not ensure catheter bags were covered and not openly displayed, as required to uphold residents' rights to dignity and respect.
Failure to Honor Resident Choice in Morning Care and Routine
Penalty
Summary
The facility failed to honor and facilitate resident self-determination by not supporting resident choice regarding waking time and morning care. One resident expressed a preference for early morning care and having her bed made before breakfast, but consistently did not receive assistance until after 10:00 AM, despite her requests and those of her family. Observations confirmed that morning care was provided much later than the resident's stated preference, and the resident's care plan did not initially reflect her wishes. The Director of Nursing acknowledged the resident's right to choose the timing of morning care but did not ensure this preference was honored prior to the deficiency being identified. Another resident also preferred to have her bed made and to get ready early in the day, but staff did not assist her until later, citing other responsibilities. This resident's preferences for her morning routine were not documented in her records, and she was observed attempting to make her own bed and get dressed without staff assistance. The lack of documentation and staff response resulted in the resident not receiving care according to her preferences.
Failure to Complete and Document Grievance Investigation
Penalty
Summary
The facility failed to ensure that all written grievance decisions included the required elements as outlined in their grievance policy. Specifically, a grievance form dated 4/10/2024 for one resident was not completed, and the incident was not logged into the grievance log. During record review, it was found that the grievance form was missing, and the administrator confirmed that a completed copy could not be located. The facility's policy requires the grievance officer to oversee grievances through conclusion, including conducting investigations and issuing written decisions, but this process was not followed for the identified grievance.
Failure to Investigate and Report Injuries and Allegations of Neglect
Penalty
Summary
The facility failed to follow its written policies and procedures regarding the investigation and reporting of injuries of unknown origin and allegations of neglect. In one instance, a resident was observed with a large bruise on her left upper arm, which she could not explain. The DON was initially unaware of the injury and, after being informed, had the nurse practitioner assess the bruise. The assessment confirmed new bruising of unknown cause. Despite facility policy requiring investigation and timely reporting of such injuries, the DON confirmed that no investigation or report was made to the appropriate authorities. In another case, a family member reported that a resident developed new Moisture Associated Skin Damage (MASD) and was not receiving regular baths. The family member filed complaints with the facility, APS, and the state licensing office. The facility did not document the complaint in its grievance log and delayed initiating an investigation until several months later. Additionally, the facility failed to submit required reports to the state licensing office regarding the allegation of neglect and the subsequent investigation, only doing so after being prompted during the survey process.
Failure to Timely Report and Investigate Alleged Abuse and Neglect
Penalty
Summary
The facility failed to timely report and investigate allegations of abuse and neglect for two residents. In the first case, a resident was observed with a large, unexplained bruise on her left upper arm. The DON was initially unaware of the injury and, after being informed, had the nurse practitioner assess the bruise. The assessment noted new bruising of unknown cause, but the DON confirmed that no investigation or report was made regarding this injury of unknown origin, despite facility policy requiring such actions for unexplained injuries. In the second case, a family member reported to authorities that a resident had developed pressure ulcers and was not receiving regular baths. The facility conducted an internal investigation and communicated with Adult Protective Services (APS), but failed to submit the required reports to the Office of Health Facility Licensure and Certification (OHFLAC) within the mandated timeframe. The initial report to OHFLAC was only submitted after the issue was identified during a survey review, indicating a lapse in timely reporting of the neglect allegation and investigation results.
Failure to Investigate and Report Injury of Unknown Origin
Penalty
Summary
A large bruise of unknown origin was observed on the left upper arm of a resident, who was unable to explain how the injury occurred. The Director of Nursing (DON) was initially unaware of the bruise and only arranged for a Nurse Practitioner (NP) to assess the injury after it was brought to her attention. The NP's assessment documented new bruising of unknown cause on the resident's upper arms, with the resident denying any pain. The resident also had old bruises on her hands, likely from previous IV insertion sites. Despite the facility's policy requiring investigation and reporting of injuries of unknown origin, the DON confirmed that she did not report or investigate the incident as required. The policy specifically defines injuries of unknown source and mandates that such events be investigated to determine if abuse or neglect is suspected, and reported to appropriate authorities within specified timeframes. The failure to follow these procedures resulted in the deficiency.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADLs) according to the assessed needs of a dependent resident. During an interview and observation, a resident reported not receiving showers or baths as ordered or preferred, expressing dissatisfaction with her hygiene, especially when receiving visitors. The resident was observed to have very oily hair at the time of the interview. A review of the resident's ADL documentation over a 30-day period revealed only one shower and two bed baths were provided. The facility administrator confirmed there was no documentation showing that the resident received showers as scheduled.
Failure to Provide Timely Incontinence Care and Assessments
Penalty
Summary
Facility staff failed to implement protocols to ensure that dependent residents received incontinence assessments and care at the required intervals. A resident who was incontinent and dependent on staff for care was not checked or provided incontinence care in a timely manner. The resident's Medical Power of Attorney (MPOA) reported that she frequently found the resident soiled upon her arrival and had to clean him herself, indicating that staff were not assessing or addressing the resident's incontinence needs regularly. Record review showed documentation that the resident was assessed for incontinence, but further investigation revealed that after an initial check at 7:00 AM, no additional assessments were recorded for the remainder of the morning. The nursing assistant assigned to the resident confirmed that checks should occur every two hours but admitted that no further checks had been performed after the initial morning assessment. The Director of Nursing also confirmed that residents should be checked at least every two hours.
Failure to Complete and Address Pharmacist Medication Regimen Reviews
Penalty
Summary
Surveyors found that the facility failed to ensure that a licensed pharmacist's monthly medication regimen reviews (MMRs) were completed and that any identified irregularities were reviewed and addressed by the attending physician, as required by facility policy. For two of five residents reviewed, there was no evidence that the physician responded to pharmacist recommendations regarding medication management. Specifically, for one resident, the MMR for December was missing, and the physician did not respond to a recommendation about blood pressure monitoring and medication instructions. For another resident, the MMR for December was also missing, and there was no physician response to a pharmacist's inquiry about the appropriate dosage of a topical medication. The Director of Nursing confirmed during interviews that the required documentation and physician responses were not available for these residents.
Failure to Provide Resident-Requested Breakfast Items
Penalty
Summary
A resident with a history of protein-calorie malnutrition, unintended weight loss, and a varied appetite repeatedly requested cereal and milk for breakfast, but did not receive it despite multiple requests from both the resident and her family member. The family member highlighted the cereal option on the resident's breakfast menu, and photographic evidence showed oatmeal was present, but not the requested cold cereal. The resident's care plan indicated she was at nutritional risk, required encouragement to eat, and was on a regular diet with dysphagia advanced texture and regular liquids, with house supplements provided three times daily. Despite the resident's tray ticket clearly listing both oatmeal and corn flakes, with these items bolded and underlined for emphasis, the resident did not receive the corn flakes on at least two observed occasions. Staff interviews confirmed the omission, with an RN stating that kitchen staff frequently forgot to include requested items on residents' trays, requiring nursing staff to retrieve missing items from the kitchen. The deficiency centers on the facility's failure to honor and implement the resident's stated food preferences, as documented and communicated, in accordance with her care plan and dietary orders.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to ensure that all staff had thorough background checks as required by the state of Virginia. Specifically, Nurse Aide (NA) #17 did not have a WV CARES eligibility letter on file, which is necessary to determine eligibility to work in a nursing home. NA #17 was hired on 05/08/06, and the WV CARES system became mandatory for all new and current employees starting in 2016. Despite this requirement, NA #17 continued to work at the facility without the necessary documentation. The Director of Nursing confirmed that NA #17 had been working prior to an illness and acknowledged the absence of the WV CARES eligibility screening documentation. This deficiency was identified during a review of five staff members' records, with NA #17 being the only one lacking the required documentation.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was available for eight consecutive hours a day, seven days a week, which had the potential to affect all residents at the facility. A review of the facility staff postings and timecards revealed that on two specific dates, 11/19/23 and 12/03/23, no RN was scheduled or worked. During an interview, the Director of Nursing confirmed the absence of RN coverage on these dates and attributed it to being very short-staffed.
Failure to Retain Staff Posting Records
Penalty
Summary
The facility failed to retain the original staff postings for a minimum of 18 months as required by regulations. This deficiency was identified during a survey when the Director of Nursing (DON) was unable to provide the original Staff Posting Sheets for the first quarter of 2024. The issue was discovered on March 26, 2024, at 3:45 PM, and confirmed on March 27, 2024, at 9:10 AM, when the DON stated that the facility could not find the original documents. This failure had the potential to affect all 58 residents currently residing at the facility.
Improper Waste Containment in Dumpster Area
Penalty
Summary
The facility failed to properly contain waste in the dumpster area, affecting more than an isolated number of residents. Observations were made on three separate occasions, revealing trash scattered around the dumpster and in the community yard between the dumpster and the city road. The trash included used gloves, masks, cigarette packages, and cigarette butts. On March 25, 2024, at 1:05 PM, these items were observed around and behind the dumpster, extending from the fence to the city road. A second observation on March 26, 2024, at 11:10 AM confirmed the presence of similar waste in the same areas. A third observation on March 27, 2024, at 10:45 AM, conducted with the Administrator, again found trash around the dumpster and extending to the city road.
Failure to Support Resident Shower Preferences
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by not supporting resident choices related to shower schedules. This deficiency was identified for seven residents, all of whom expressed dissatisfaction with the frequency and timing of their showers. Resident #26 reported receiving showers only once every two weeks despite requesting more frequent showers. Similarly, Resident #4 experienced infrequent showers and was not allowed to walk without assistance due to recent falls, which further limited her ability to shower as desired. Resident #3 expressed a preference for two to three showers per week but only received two showers in a three-week period. Resident #11's shower schedule conflicted with his preferred activities, such as Bingo, and he was not offered alternative shower times. Resident #12 was not given a choice between a shower or a bed bath, as outlined in her care plan, and received only two showers in the past month. Resident #36 reported inconsistent shower availability, with no showers documented in the past 14 days. Resident #1 also experienced delays in receiving showers and had only three showers documented in the past 30 days. The Director of Nursing acknowledged the ongoing issues with shower schedules and documentation, confirming that the facility was aware of the problem but had not yet resolved it. The lack of adherence to resident preferences and inadequate documentation contributed to the deficiency in promoting resident self-determination.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for several residents, leading to deficiencies in their care. Resident #19, who was on a fluid restriction due to a renal diet, was observed receiving more fluids than prescribed, with no care plan in place to manage this restriction. Additionally, Resident #19, who is legally blind, did not have a care plan addressing her visual impairment in relation to her activities of daily living. Resident #24, who was prescribed Lasix for edema, also lacked a care plan to address this condition. Resident #50, diagnosed with Alzheimer's disease and dementia with behavioral disturbances, was prescribed medications to manage these conditions, yet there was no care plan in place to address the dementia or Alzheimer's disease. Furthermore, Resident #33, who has hemiplegia and hemiparesis following a cerebral infarction affecting the left side, expressed concerns about the placement of his call light, which was often out of reach due to his limited mobility. The care plan did not address the need for the call light to be placed on his right side, leading to increased anxiety for the resident.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to administer medications as ordered by the physician for several residents, leading to significant delays in medication administration. For instance, a resident with a diagnosis of gangrene and diabetes received Gabapentin and Piperacillin-Tazobactam intravenously hours later than prescribed. Another resident with multiple sclerosis and diabetes experienced delays in receiving insulin, which was crucial for controlling blood glucose levels. These delays were acknowledged by the Director of Nursing, who confirmed that the medications were not administered within the facility's policy timeframe. In addition to medication administration issues, the facility did not complete required neurological checks following a resident's unwitnessed fall. The nursing staff failed to obtain vital signs at the specified intervals, missing several checks over a period of hours. This lapse was confirmed by the Director of Nursing, who agreed that the neurological evaluation flow sheet was incomplete. Furthermore, the facility did not report a critical oxygen saturation level to a physician for a resident with a history of congestive heart failure and atelectasis. The resident's oxygen level dropped to 85%, but there was no evidence that the physician was notified, which is a standard practice when such a critical level is observed. This oversight was confirmed by a registered nurse, who emphasized the importance of notifying a physician in such situations to potentially obtain an order for supplemental oxygen.
Medication Cart Security Lapse
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards, specifically regarding the security of medication carts. During an observation, a medication cart on the 400 Hall was found unlocked and unattended, which could allow unauthorized access to medications by residents or other individuals. The Director of Nursing confirmed the presence of medications in the cart and acknowledged that it should have been locked when unattended. An LPN noted that the lock on the cart was faulty, demonstrating how it could appear locked without actually being secure. The facility's policy mandates that medication carts must always be locked when out of sight or unattended, but this was not adhered to in this instance.
Failure to Monitor Medication Side Effects and Behaviors
Penalty
Summary
The facility failed to adequately monitor and document the side effects and behaviors associated with the administration of antianxiety and antidepressant medications for three residents. Resident #50, diagnosed with Alzheimer's disease, dementia with behavior disturbance, and anxiety disorder, was prescribed buspirone HCL to manage anxiety and restlessness. However, there was no documentation in the Medication Administration Record or progress notes regarding the monitoring of side effects such as sedation, morning hangover, ataxia, and nausea, as required by the physician's order. This lack of documentation was confirmed by the Director of Nursing (DON). Similarly, Resident #24, who had recurrent depressive disorder, dementia, Alzheimer's disease with late onset, psychotic disturbance, mood disturbance, and anxiety disorder, was prescribed duloxetine HCL and lorazepam. The facility failed to document the monitoring of side effects and behaviors as specified in the physician's orders for these medications. Additionally, for Resident #10, who was receiving lorazepam for seizures, the DON acknowledged that the monitoring records only indicated a simple 'yes' or 'no' without specifying the behaviors or side effects observed, which was insufficient for proper monitoring.
Failure to Provide Evening Snacks to All Residents
Penalty
Summary
The facility failed to provide a substantial and nourishing snack between the evening meal and breakfast, potentially affecting all residents without a dietary order for an evening snack or those unable to request one due to cognitive or physical limitations. During a resident council meeting, residents reported that the facility did not offer an evening snack, although they believed most residents would appreciate one. Some residents mentioned they could request a snack from the nurse's station if they were hungry before bedtime, but it was unclear if all residents knew how to do this. In a staff interview, an LPN working the evening shift confirmed that snacks were provided only to residents with a diagnosed need and a physician's dietary order. The LPN did not recall snacks being offered to all residents. A tour of the nutrition room revealed limited snack options, with only pre-packaged honey graham crackers available.
Infection Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by two specific incidents. In the first incident, a resident was observed with gauze and tape around the left front of their wheelchair, which was intended to protect the resident's leg from rubbing against the wheelchair. However, the gauze and tape could not be cleaned, posing a potential infection risk. This was pointed out to a registered nurse, but no further information was provided by the Director of Nursing. In the second incident, a physical therapist assistant was observed performing therapy on a resident who was under transmission-based contact precautions for Clostridioides difficile (CDiff). Despite a sign indicating the need for appropriate personal protective equipment (PPE) and the use of soap and water instead of sanitizer, the assistant did not wear PPE and used hand sanitizer upon exiting the room. This was confirmed by both the assistant and the Director of Nursing, with no additional information provided.
Deficiencies in Resident Care and Rights
Penalty
Summary
The facility failed to treat a resident with respect and dignity by not assisting her with personal grooming, specifically the removal of facial hair. During a dining room observation, the resident was seen with noticeable facial hair, which she expressed a desire to have removed. The resident required supervision and personal assistance for personal hygiene, as indicated in her medical records. The issue was confirmed by the Administrator, who acknowledged the presence of the facial hair and stated that staff would address it. Later, the resident expressed happiness after the facial hair was removed, indicating the deficiency in timely personal care assistance. Additionally, the facility did not serve meals to residents in the dining room simultaneously, leading to staggered meal times at the same table. Observations showed significant delays in serving meals to residents seated at the same table, with some waiting up to 20 minutes longer than others. Staff interviews revealed that this was not the usual practice, but an issue in the kitchen caused the delay. Furthermore, the facility failed to ensure a resident's right to vote was upheld, as the resident was not asked about voting in the upcoming election, despite having a care plan that emphasized the importance of voting to him. The facility had no record of the resident voting in the 2020 election, although he had participated in previous elections.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident #33, who had limited mobility due to a stroke affecting the left side of his body. During a resident council meeting, the resident expressed a preference for the call light to be pinned to his clothing or placed on the blanket beside him on the right side, as he was unable to reach it when it was placed on the left side. A subsequent observation confirmed that the call light was indeed placed on the left side, looped around the bed rail, and out of reach for the resident. This situation was confirmed by LPN #34, who acknowledged the call light's placement on the resident's nondominant side.
Failure to Notify Legal Guardian of Resident's Fall
Penalty
Summary
The facility failed to notify the legal guardian of a resident after the resident experienced a fall. The resident, who lacked the capacity to make medical decisions, had the West Virginia Department of Health and Human Resources (WV DHHR) appointed as their legal guardian. Despite this, the facility only attempted to contact the resident's son, leaving voicemail messages, but did not notify the legal guardian as required. The resident's fall was documented in the medical records, and the son was informed during a visit the following day, but there was no evidence that the WV DHHR was contacted. The deficiency was confirmed through a record review and staff interviews. The Director of Social Services acknowledged that the WV DHHR should have been contacted regarding any changes in the resident's condition. The Director of Nursing also indicated that the Change in Condition report should have reflected contact with the WV DHHR. However, the report only showed attempts to contact the resident's son, with no documentation of notification to the legal guardian, highlighting a failure in communication protocols for residents with legal guardians.
Privacy Breach in Resident Care and Information Handling
Penalty
Summary
The facility failed to maintain the personal privacy of a resident during catheter care. During an observation, a nurse aide did not close the door or window blinds while providing catheter care to a resident, compromising the resident's privacy. This incident was reported to the Director of Nursing, but no further information was provided. Additionally, the facility did not protect the confidentiality of residents' personal information. An elopement binder containing sensitive information, such as resident pictures, elopement risk identification forms, and admission record face sheets, was found unattended in the lobby. This binder was accessible to the public and contained personal details like dates of birth, distinguishing characteristics, and partial social security numbers of three residents. The facility administrator acknowledged this as a privacy issue, noting that the binder should have been kept in the front office.
Failure to Address Resident's Grievance Regarding Missing Wheelchair
Penalty
Summary
The facility failed to properly identify and address a grievance related to a resident's missing personal property, specifically a wheelchair provided by the veteran's administration. The grievance process, overseen by the social services department, was not followed as the verbal complaint made by the resident was not documented or tracked as a formal grievance. The resident had reported the missing wheelchair multiple times to various staff members, including nurses, activities staff, and aides, but did not receive any follow-up or resolution. The social worker responsible for the grievance process was unable to provide documentation of the grievance and assumed the issue was resolved when the wheelchair was initially found, but did not acknowledge the second instance of it going missing. During a resident council meeting, the resident expressed frustration over the lack of response and resolution regarding his missing wheelchair. Despite the facility's grievance policy requiring prompt acknowledgment and resolution of grievances, the resident's concerns were not addressed in a timely manner, and he was not kept informed of any progress. The social worker's failure to document and track the grievance led to a lack of communication and resolution, resulting in the resident's continued lack of access to his personal wheelchair.
Failure to Update PASRR for Resident with Major Depressive Disorder
Penalty
Summary
The facility failed to update the Preadmission Screening and Resident Review (PASRR) for a resident after they were diagnosed with Major Depressive Disorder. The resident's most recent PASRR was dated January 9, 2014, and did not include the diagnosis of Major Depressive Disorder, which was made on November 10, 2014. This oversight was confirmed by the Director of Nursing, who acknowledged that a new PASRR should have been completed to reflect the resident's updated mental health status.
Failure to Update Dialysis Schedule in Care Plan
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident in a timely manner, as identified during a long-term care survey. The resident, who requires dialysis three times a week, had a care plan that inaccurately reflected the dialysis pick-up time. Initially, the care plan stated that the resident was to be picked up at 05:30 AM for dialysis on Monday, Wednesday, and Friday. However, the pick-up time had been changed to 10:00 AM at the beginning of the year, a fact confirmed by the Director of Nursing. Despite this change, the care plan was not updated to reflect the new dialysis schedule, leading to a discrepancy between the care plan and the actual care provided.
Facility's Failure to Maintain Resident Hygiene
Penalty
Summary
During a routine inspection, it was observed that the facility failed to provide adequate care to a resident, specifically in maintaining personal hygiene. The resident, identified as #7, was noted to have unkempt hair, indicating a lack of proper grooming. This neglect in care was evident during the inspection, highlighting a significant lapse in the facility's responsibility to maintain the resident's hygiene. The facility's failure to provide necessary care to the resident was a clear violation of the required standards, leading to the identification of the deficiency.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received the necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Resident #27 had several physician-ordered treatments for pressure ulcers that were not completed as scheduled. These included the application of skin prep and protective cream to deep tissue injuries on the right and left heels, which were missed on specific evening shifts. Additionally, the resident was supposed to have pillows placed under their feet to keep heels elevated and floating, but this was not consistently done as ordered. Further deficiencies were noted in the care of the resident's pressure wounds. The cleansing and dressing of a Stage III pressure wound on the sacrum and unstageable pressure injuries on both heels were not performed on designated days. The facility also failed to check the low air loss mattress every shift as required for pressure injury management. These missed treatments and checks were confirmed by the Director of Nursing, indicating a lapse in adherence to the prescribed care plan for the resident.
Deficiencies in Respiratory Care for Two Residents
Penalty
Summary
The facility failed to provide proper respiratory care for two residents, leading to deficiencies in their treatment. For Resident #41, the facility's policy on tracheostomy care was not followed. During an observation, a registered nurse did not clear and disinfect the bedside table before opening the tracheostomy kit. The nurse placed the sterile drape on the resident's chest and abdomen instead of the bedside table and mixed the sterile contents with personal belongings, compromising the sterile field. This action was contrary to the facility's policy, which required the use of aseptic techniques and maintaining a sterile field. For Resident #4, the facility failed to administer breathing treatments as ordered by the physician. The resident reported not receiving her prescribed Albuterol Sulfate inhalation treatments for several days. A review of the electronic medication administration record confirmed that the treatments were not documented as given on multiple occasions over several days. The Director of Nursing confirmed that the resident did not receive the ordered treatments, indicating a lapse in following the physician's orders for respiratory care.
Failure to Ensure Proper Dialysis Care and Fluid Restriction
Penalty
Summary
The facility failed to provide ongoing assessments to ensure the overall quality of care for a resident receiving dialysis treatment. Specifically, the Hemodialysis Communication Records for the resident were either incomplete or missing on multiple occasions. These records are crucial as they include post-dialysis assessments such as access site checks, vital signs, and any post-dialysis complications or new orders from the dialysis center. The lack of complete records was confirmed by the Director of Nursing. Additionally, the facility did not adhere to the physician's order for the resident's fluid restriction. The resident was observed receiving a total of 32 ounces of fluid during a meal, which exceeded the prescribed fluid restriction of 8 ounces per meal. The resident's meal ticket indicated a fluid restriction of 1000 ml per 24 hours, with specific allocations for each meal and medication pass. This discrepancy was confirmed by a registered nurse.
Failure to Monitor Antipsychotic Medication Side Effects
Penalty
Summary
The facility failed to monitor for side effects and behaviors associated with antipsychotic medications for two residents. Resident #50, diagnosed with Alzheimer's disease, dementia with behavior disturbance, and anxiety disorder, was prescribed Olanzapine to be administered every other day for dementia with paranoia. However, there was no documentation in the Medication Administration Record or progress notes regarding the monitoring of side effects such as sedation, weight gain, dry mouth, blurred vision, tachycardia, and tardive dyskinesia, as required by the physician's order. This lack of documentation was confirmed by the Director of Nursing. Similarly, Resident #27, who also had dementia with behavioral disturbances and Alzheimer's disease, was prescribed Seroquel for targeted behaviors like hitting. The physician's order required monitoring for side effects including sedation, dry mouth, blurred vision, drowsiness, apathy, constipation, rigidity, drooling, weight gain, edema, hypotension, and akathisia. However, there was no documentation of the resident's behaviors or monitoring of these side effects in the Medication Administration Record or progress notes. This deficiency was also confirmed by the Director of Nursing.
Latest citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
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